Obsessive–compulsive disorder (OCD) is an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear or worry (obsessions), repetitive behaviors aimed at reducing the associated anxiety (compulsions), or a combination of such obsessions and compulsions. Symptoms of the disorder include excessive washing or cleaning, repeated checking, extreme hoarding, preoccupation with sexual, violent or religious thoughts, relationship-related obsessions, aversion to particular numbers and nervous rituals such as opening and closing a door a certain number of times before entering or leaving a room. These symptoms are time-consuming, might result in loss of relationships with others, and often cause severe emotional and financial distress. The acts of those who have OCD may appear paranoid and potentially psychotic. However, people with OCD generally recognize their obsessions and compulsions as irrational and may become further distressed by this realization. Despite the irrational behaviour, OCD is associated with above-average intelligence.[1]

Obsessive–compulsive disorder affects children and adolescents, as well as adults. Roughly one third to one half of adults with OCD report a childhood onset of the disorder, suggesting the continuum of anxiety disorders across the lifespan.[6] The phrase obsessive–compulsive has become part of the English lexicon, and is often used in an informal or caricatured manner to describe someone who is excessively meticulous, perfectionistic, absorbed, or otherwise fixated.[7]

Signs and symptoms

Obsessions

People with OCD may face horrific intrusive thoughts, such as thoughts about the devil (shown is a painted interpretation of Hell)

Obsessions are thoughts that recur and persist despite efforts to ignore or confront them.[8] People with OCD frequently perform tasks, or compulsions, to seek relief from obsession-related anxiety. Within and among individuals, the initial obsessions, or intrusive thoughts, vary in their clarity and vividness. A relatively vague obsession could involve a general sense of disarray or tension accompanied by a belief that life cannot proceed as normal while the imbalance remains. A more intense obsession could be a preoccupation with the thought or image of someone close to them dying[9][10] or intrusions related to "relationship rightness."[11] Other obsessions concern the possibility that someone or something other than oneself—such as God, the Devil, or disease—will harm either the person with OCD or the people or things that the person cares about. Other individuals with OCD may experience the sensation of invisible protrusions emanating from their bodies, or have the feeling that inanimate objects are ensouled.[12]

Some people with OCD experience sexual obsessions that may involve intrusive thoughts or images of "kissing, touching, fondling, oral sex, anal sex, intercourse, incest and rape" with "strangers, acquaintances, parents, children, family members, friends, coworkers, animals and religious figures", and can include "heterosexual or homosexual content" with persons of any age.[13] As with other intrusive, unpleasant thoughts or images, most "normal" people have some disquieting sexual thoughts at times, but people with OCD may attach extraordinary significance to the thoughts. For example, obsessive fears about sexual orientation can appear to the person with OCD, and even to those around them, as a crisis of sexual identity.[14][15] Furthermore, the doubt that accompanies OCD leads to uncertainty regarding whether one might act on the troubling thoughts, resulting in self-criticism or self-loathing.[13]

People with OCD understand that their notions do not correspond with reality; however, they feel that they must act as though their notions are correct. For example, an individual who engages in compulsive hoarding might be inclined to treat inorganic matter as if it had the sentience or rights of living organisms, while accepting that such behavior is irrational on a more intellectual level.

Primarily obsessional

OCD sometimes manifests without overt compulsions.[16] Nicknamed "Pure-O",[17] or referred to as Primarily Obsessional OCD, OCD without overt compulsions could, by one estimate, characterize as many as 50 percent to 60 percent of OCD cases.[18] Primarily obsessional OCD has been called "one of the most distressing and challenging forms of OCD."[19] People with this form of OCD have "distressing and unwanted thoughts pop into [their] head frequently", and the thoughts "typically center on a fear that you may do something totally uncharacteristic of yourself, something ...potentially fatal...to yourself or others."[19] The thoughts "quite likely, are of an aggressive or sexual nature."[19]

Rather than engaging in observable compulsions, the person with this subtype might perform more covert, mental rituals, or might feel driven to avoid the situations in which particular thoughts seem likely to intrude.[17] As a result of this avoidance, people can struggle to fulfill both public and private roles, even if they place great value on these roles and even if they had fulfilled the roles successfully in the past.[17] Moreover, the individual's avoidance can confuse others who do not know its origin or intended purpose, as it did in the case of a man whose wife began to wonder why he would not hold their infant child.[17] The covert mental rituals can take up a great deal of a person's time during the day.

Compulsions

Some people with OCD perform compulsive rituals because they inexplicably feel they have to, others act compulsively so as to mitigate the anxiety that stems from particular obsessive thoughts. The person might feel that these actions somehow either will prevent a dreaded event from occurring, or will push the event from their thoughts. In any case, the individual's reasoning is so idiosyncratic or distorted that it results in significant distress for the individual with OCD or for those around them. Excessive skin picking (i.e., dermatillomania) or hair plucking (i.e., trichotillomania) and nail biting (i.e., onychophagia) are all on the obsessive–compulsive spectrum. Individuals with OCD are aware that their thoughts and behavior are not rational,[20] but they feel bound to comply with them to fend off feelings of panic or dread.

Some common compulsions include counting specific things (such as footsteps) or in specific ways (for instance, by intervals of two), and doing other repetitive actions, often with atypical sensitivity to numbers or patterns. People might repeatedly wash their hands[21] or clear their throats, make sure certain items are in a straight line, repeatedly check that their parked cars have been locked before leaving them, constantly organize in a certain way, turn lights on and off, keep doors closed at all times, touch objects a certain number of times before exiting a room, walk in a certain routine way like only stepping on a certain color of tile, or have a routine for using stairs, such as always finishing a flight on the same foot.

People rely on compulsions as an escape from their obsessive thoughts; however, they are aware that the relief is only temporary, that the intrusive thoughts will soon return. Some people use compulsions to avoid situations that may trigger their obsessions. Although some people do certain things over and over again, they do not necessarily perform these actions compulsively. For example, bedtime routines, learning a new skill, and religious practices are not compulsions. Whether or not behaviors are compulsions or mere habit depends on the context in which the behaviors are performed. For example, arranging and ordering DVDs for eight hours a day would be expected of one who works in a video store, but would seem abnormal in other situations. In other words, habits tend to bring efficiency to one's life, while compulsions tend to disrupt it.[23]

In addition to the anxiety and fear that typically accompanies OCD, sufferers may spend hours performing such compulsions every day. In such situations, it can be hard for the person to fulfill their work, family, or social roles. In some cases, these behaviors can also cause adverse physical symptoms. For example, people who obsessively wash their hands with antibacterial soap and hot water can make their skin red and raw with dermatitis.[24]

People with OCD can use rationalizations to explain their behavior; however, these rationalizations do not apply to the overall behavior but to each instance individually. For example, a person compulsively checking the front door may argue that the time taken and stress caused by one more check of the front door is much less than the time and stress associated with being robbed, and thus checking is the better option. In practice, after that check, the person is still not sure and deems it is still better to perform one more check, and this reasoning can continue as long as necessary.

Overvalued ideas

Some OCD sufferers exhibit what is known as overvalued ideas. In such cases, the person with OCD will truly be uncertain whether the fears that cause them to perform their compulsions are irrational or not. After some discussion, it is possible to convince the individual that their fears may be unfounded. It may be more difficult to do ERP therapy on such patients because they may be unwilling to cooperate, at least initially. There are severe cases in which the sufferer has an unshakeable belief in the context of OCD that is difficult to differentiate from psychosis.[25]

Behaviorally, there is some research demonstrating a link between drug addiction and the disorder as well. For example, there is a higher risk of drug addiction among those with any anxiety disorder (possibly as a way of coping with the heightened levels of anxiety), but drug addiction among OCD patients may serve as a type of compulsive behavior and not just as a coping mechanism. Depression is also extremely prevalent among sufferers of OCD. One explanation for the high depression rate among OCD populations was posited by Mineka, Watson, and Clark (1998), who explained that people with OCD (or any other anxiety disorder) may feel depressed because of an "out of control" type of feeling.[22]

Some with OCD present with features typically associated with Tourette's syndrome, such as compulsions that may appear to resemble motor tics; this has been termed "tic-related OCD" or "Tourettic OCD".[32][33]

Causes

Scholars generally agree that both psychological and biological factors play a role in causing the disorder, although they differ in their degree of emphasis upon either type of factor.

Psychological

An evolutionary psychology view is that moderate versions of compulsive behavior may have had evolutionary advantages. Examples would be moderate constant checking of hygiene, the hearth, or the environment for enemies. Similarly, hoarding may have had evolutionary advantages. In this view OCD may be the extreme statistical "tail" of such behaviors possibly due to a high amount of predisposing genes.[34]

Biological

OCD has been linked to abnormalities with the neurotransmitterserotonin, although it could be either a cause or an effect of these abnormalities. Serotonin is thought to have a role in regulating anxiety. To send chemical messages from one neuron to another, serotonin must bind to the receptor sites located on the neighboring nerve cell. It is hypothesized that the serotonin receptors of OCD sufferers may be relatively understimulated. This suggestion is consistent with the observation that many OCD patients benefit from the use of selective serotonin reuptake inhibitors (SSRIs), a class of antidepressant medications that allow for more serotonin to be readily available to other nerve cells.[35]

A possible genetic mutation may contribute to OCD. A mutation has been found in the human serotonin transporter gene, hSERT, in unrelated families with OCD.[36] Moreover, data from identical twins supports the existence of a "heritable factor for neurotic anxiety".[37] Further, individuals with OCD are more likely to have first-degree family members exhibiting the same disorders than do matched controls. In cases where OCD develops during childhood, there is a much stronger familial link in the disorder than cases in which OCD develops later in adulthood. In general, genetic factors account for 45–65% of OCD symptoms in children diagnosed with the disorder.[38] Environmental factors also play a role in how these anxiety symptoms are expressed; various studies on this topic are in progress and the presence of a genetic link is not yet definitely established.

People with OCD evince increased grey matter volumes in bilateral lenticular nuclei, extending to the caudate nuclei, while decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri.[39][40] These findings contrast with those in people with other anxiety disorders, who evince decreased (rather than increased) grey matter volumes in bilateral lenticular / caudate nuclei, while also decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri.[40]Orbitofrontal cortex overactivity is attenuated in patients who have successfully responded to SSRI medication, a result believed to be caused by increased stimulation of serotonin receptors 5-HT2A and 5-HT2C.[41] The striatum, linked to planning and the initiation of appropriate actions, has also been implicated; mice genetically engineered with a striatal abnormality exhibit OCD-like behavior, grooming themselves three times as frequently as ordinary mice.[42] Recent evidence supports the possibility of a heritable predisposition for neurological development favoring OCD.[43]

Neurotransmitters

Researchers have yet to pinpoint the exact cause of OCD, but brain differences, genetic influences, and environmental factors are being studied. Brain scans of people with OCD have shown that they have different patterns of brain activity than people without OCD and that different functioning of circuitry within a certain part of the brain, the striatum, may cause the disorder. Differences in other parts of the brain and neurotransmitter dysregulation, especially serotonin and dopamine, may also contribute to OCD.[47] Independent studies have consistently found unusual dopamine and serotonin activity in various regions of the brain in individuals with OCD. These can be defined as dopaminergichyperfunction in the prefrontal cortex (mesocortical dopamine pathway) and serotonergichypofunction in the basal ganglia.[48][49][50]Glutamate dysregulation has also been the subject of recent research,[51][52] although its role in the disorder's etiology is not yet clear. Glutamate is known to act as a cotransmitter with dopamine in dopamine pathways that project out of the ventral tegmental area.

Diagnosis

Cleaning is not an OCD activity per se; thoughts, impulses, or images about a topic like cleaning must be of a degree or type that lies outside the normal range of worries about conventional problems.

Formal diagnosis may be performed by a psychologist, psychiatrist, clinical social worker, or other licensed mental health professional. To be diagnosed with OCD, a person must have obsessions, compulsions, or both, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The Quick Reference to the 2000 edition of the DSM states that several features characterize clinically significant obsessions and compulsions. Such obsessions, the DSM says, are recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and that cause marked anxiety or distress. These thoughts, impulses, or images are of a degree or type that lies outside the normal range of worries about conventional problems.[53] A person may attempt to ignore or suppress such obsessions, or to neutralize them with some other thought or action, and will tend to recognize the obsessions as idiosyncratic or irrational.

Compulsions become clinically significant when a person feels driven to perform them in response to an obsession, or according to rules that must be applied rigidly, and when the person consequently feels or causes significant distress. Therefore, while many people who do not suffer from OCD may perform actions often associated with OCD (such as ordering items in a pantry by height), the distinction with clinically significant OCD lies in the fact that the person who suffers from OCD must perform these actions, otherwise they will experience significant psychological distress. These behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these activities are not logically or practically connected to the issue, or they are excessive. In addition, at some point during the course of the disorder, the individual must realize that their obsessions or compulsions are unreasonable or excessive.

Moreover, the obsessions or compulsions must be time-consuming (taking up more than one hour per day) or cause impairment in social, occupational, or scholastic functioning.[53] It is helpful to quantify the severity of symptoms and impairment before and during treatment for OCD. In addition to the patient’s estimate of the time spent each day harboring obsessive-compulsive thoughts or behaviors, Fenske and Schwenk in their article "Obsessive-Compulsive Disorder: Diagnosis and Management," argue that more concrete tools should be used to gauge the patient’s condition (2009). This may be done with rating scales, such as the Yale–Brown Obsessive Compulsive Scale (Y-BOCS). With measurements like these, psychiatric consultation can be more appropriately determined because it has been standardized.[29]

Differential diagnosis

OCD is often confused with the separate condition obsessive–compulsive personality disorder (OCPD). OCD is egodystonic, meaning that the disorder is incompatible with the sufferer's self-concept.[54][55] Because ego dystonic disorders go against a person's self-concept, they tend to cause much distress. OCPD, on the other hand, is egosyntonic — marked by the person's acceptance that the characteristics and behaviours displayed as a result are compatible with his or her self-image, or are otherwise appropriate, correct or reasonable.

As a result, people with OCD are often aware that their behavior is not rational, are unhappy about their obsessions but nevertheless feel compelled by them, and may be riddled with anxiety.[56] By contrast people with OCPD are not aware of anything abnormal; they will readily explain why their actions are rational, it is usually impossible to convince them otherwise, and they tend to derive pleasure from their obsessions or compulsions.[56]

OCD is different from behaviors such as gambling addiction and overeating. People with these disorders typically experience at least some pleasure from their activity; OCD sufferers may not actively want to perform their compulsive tasks and experience no pleasure from doing so.

Behavioral therapy

One exposure and ritual prevention activity would be to check the lock only once, and then leave.

The specific technique used in BT/CBT is called exposure and ritual prevention (also known as "exposure and response prevention") or ERP; this involves gradually learning to tolerate the anxiety associated with not performing the ritual behavior. At first, for example, someone might touch something only very mildly "contaminated" (such as a tissue that has been touched by another tissue that has been touched by the end of a toothpick that has touched a book that came from a "contaminated" location, such as a school.) That is the "exposure". The "ritual prevention" is not washing. Another example might be leaving the house and checking the lock only once (exposure) without going back and checking again (ritual prevention). The person fairly quickly habituates to the anxiety-producing situation and discovers that their anxiety level has dropped considerably; they can then progress to touching something more "contaminated" or not checking the lock at all—again, without performing the ritual behavior of washing or checking.[59]

Exposure ritual/response prevention (ERP) has a strong evidence base. It is considered the most effective treatment for OCD.[59] However, this claim has been doubted by some researchers criticizing the quality of many studies.[60]

It has generally been accepted that psychotherapy, in combination with psychiatric medication, is more effective than either option alone. However, more recent studies have shown no difference in outcomes for those treated with the combination of medicine and CBT versus CBT alone.[61]

Medication

SSRIs are a second line treatment of adult obsessive compulsive disorder (OCD) with mild functional impairment and as first line treatment for those with moderate or severe impairment. In children, SSRIs can be considered as a second line therapy in those with moderate-to-severe impairment, with close monitoring for psychiatric adverse effects.[62] SSRIs are efficacious in the treatment of OCD; patients treated with SSRIs are about twice as likely to respond to treatment as those treated with placebo.[63][64] Efficacy has been demonstrated both in short-term treatment trials of 6 to 24 weeks and in discontinuation trials of 28 to 52 weeks duration.[65][66][67]

The atypical antipsychotics such as quetiapine have also been found to be useful when used in addition to an SSRI in treatment-resistant OCD. However, these drugs are often poorly tolerated, and have metabolic side effects that limit their use. None of the atypical antipsychotics appear to be useful when used alone.[5]

Electroconvulsive therapy

Psychosurgery

For some, medication, support groups and psychological treatments fail to alleviate obsessive–compulsive symptoms. These patients may choose to undergo psychosurgery as a last resort. In this procedure, a surgical lesion is made in an area of the brain (the cingulate cortex). In one study, 30% of participants benefited significantly from this procedure.[69]Deep-brain stimulation and vagus nerve stimulation are possible surgical options that do not require destruction of brain tissue. In the US, the Food and Drug Administration approved deep-brain stimulation for the treatment of OCD under a humanitarian device exemption requiring that the procedure be performed only in a hospital with specialist qualifications to do so.[70]

In the US, psychosurgery for OCD is a treatment of last resort and will not be performed until the patient has failed several attempts at medication (at the full dosage) with augmentation, and many months of intensive cognitive–behavioral therapy with exposure and ritual/response prevention.[71] Likewise, in the United Kingdom, psychosurgery cannot be performed unless a course of treatment from a suitably qualified cognitive–behavioral therapist has been carried out.

Children

Therapeutic treatment may be effective in reducing ritual behaviors of OCD for children and adolescents.[72] Family involvement, in the form of behavioral observations and reports, is a key component to the success of such treatments.[73] Parental intervention also provides positive reinforcement for a child who exhibits appropriate behaviors as alternatives to compulsive responses. After one or two years of therapy, in which a child learns the nature of his or her obsession and acquires strategies for coping, that child may acquire a larger circle of friends, exhibit less shyness, and become less self-critical.[74]

Although the causes of OCD in younger age groups range from brain abnormalities to psychological preoccupations, life stress such as bullying and traumatic familial deaths may also contribute to childhood cases of OCD, and acknowledging these stressors can play a role in treating the disorder.[75]

OCD occurs in between 1 to 3% of children and adults.[76] It occurs equally in both sexes. In 80% of cases, symptoms present before the age of 18.[better source needed][77] A 2000 study by the World Health Organization found some variety in prevalence and incidence of OCD around the world, with figures in Latin America, Africa, and Europe at two to three times those in Asia and Oceania.[78]

One Canadian study found that prevalence of OCD had little correlation with race. However, respondents who marked Judaism as their religion were overrepresented among OCD patients.[79]

Prognosis

Psychological interventions such as behavioral and cognitive-behavioral therapy as well as pharmacological treatment can lead to substantial reduction of OCD symptoms for the average patient. However, OCD symptoms may persist at moderate levels even following adequate treatment course and a completely symptom-free period is uncommon.[80]

History

From the 14th to the 16th century in Europe, it was believed that people who experienced blasphemous, sexual, or other obsessive thoughts were possessed by the Devil.[54] Based on this reasoning, treatment involved banishing the "evil" from the "possessed" person through exorcism.[81][82] In the early 1910s, Sigmund Freud attributed obsessive–compulsive behavior to unconscious conflicts that manifest as symptoms.[81] Freud describes the clinical history of a typical case of "touching phobia" as starting in early childhood, when the person has a strong desire to touch an item. In response, the person develops an "external prohibition" against this type of touching. However, this "prohibition does not succeed in abolishing" the desire to touch; all it can do is repress the desire and "force it into the unconscious".[83]

Society and culture

This ribbon represents Trichotillomania and other body focused repetitive behaviors. Concept for the ribbon was started by Jenne Schrader. Colors were voted on by the Trichotillomania Facebook community, and made official by Trichotillomania Learning Center in August of 2013

Movies and television often portray idealized representations of disorders such as OCD. These depictions may lead to increased public awareness, understanding, and sympathy for such disorders.[84] In the 1997 film As Good as it Gets, actor Jack Nicholson portrays a man "... with Obsessive Compulsive Disorder (OCD)." "Throughout the film, [he] engages in ritualistic behaviors (i.e., compulsions) that disrupt his interpersonal and professional life", a "... cinematic representation of psychopathology accurately depicts the functional interference and distress associated with OCD[.]" [85] The 2004 film The Aviator depicts the biography of Howard Hughes, with Leonardo DiCaprio in the title role. In the film, "...Hughes appears to have been affected by OCD symptoms that at times were severe and incapacitating." "Many of Hughes’ OCD symptoms were apparently quite classic, particularly his contamination-related fears." [86]The film Matchstick Men (2003), directed by Ridley Scott portrays a con-man named Roy (Nicolas Cage) who has obsessive-compulsive disorder. The film "...opens with Roy, at home, suffering with his numerous obsessive compulsive symptoms, which take the form of a need for order and cleanliness and a compulsion to open and close doors three times, whilst counting aloud, before he can walk through them."[87]

British poet, essayist, and lexicographer Samuel Johnson is an example of a historical figure with a retrospective diagnosis of OCD. He had elaborate rituals for crossing the thresholds of doorways, and repeatedly walked up and down staircases counting the steps.[88] American aviator and filmmaker Howard Hughes is known to have suffered from OCD. "Nearly two years after his death, Hughes's estate attorney called on former APA CEO Raymond D. Fowler, PhD, to conduct a psychological autopsy to determine Hughes's mental and emotional condition in his last years and to help understand the origins of his mental disorder." Fowler determined that "Hughes's fear of germs grew throughout his life, and he concurrently developed obsessive-compulsive symptoms around efforts to protect himself from germs."[89] Friends of Hughes have also mentioned his obsession with minor flaws in clothing.[90]